Healthcare Provider Details

I. General information

NPI: 1932497955
Provider Name (Legal Business Name): TEOFILO ENRIQUE MATOS SANTANA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 09/16/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4175 W 20TH AVE
HIALEAH FL
33012-5874
US

IV. Provider business mailing address

4175 W 20TH AVE
HIALEAH FL
33012-5874
US

V. Phone/Fax

Practice location:
  • Phone: 305-424-3118
  • Fax:
Mailing address:
  • Phone: 305-424-3118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number052182
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME161306
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: